The proposed longitudinal study investigates the care provided by Rural Health Clinics (RHCs) to older adults in the Southern region of the U.S., as well as the costs of that care. Accountable Care Organizations (ACOs) offer potential opportunities to RHCs despite several rural constraints to ACO participation. However, little is known about how the ACO model accommodates the unique challenges of RHCs, and the impact of RHC participation on the health disparities of rural older adults including those of minority groups. The specific aims of the study are: 1) to analyze and describe the extent of RHC participation in ACOs, and the characteristics of RHCs that choose to participate in ACOs;2) to analyze ACO participation and other factors that impact health disparities of rural populations served by RHCs;and 3) to analyze ACO participation and other factors that impact cost efficiency and preventive care effectiveness for RHC older adult patients. The major research hypotheses are: 1) A higher percentage of provider-based RHCs will participate in ACOs compared to independent RHCs;2) RHCs in networks will be more likely to participate in ACOs than unaffiliated RHCs;3) Large RHCs are more likely to participate in ACOs than small RHCs;4) RHC participation in ACOs is positively related to reduction of disparities of older adult rural patients, controlling for the effects of contextual factors;5) RHC participation in ACOs is positively related to quality of care practices, controlling for the effects of contextual factors (such as ethnic/racial distribution and rurality); 6) RHC participation in ACOs is positively related to health outcomes of older adult rural patients, controlling for the effects o contextual factors (such as ethnic/racial distribution and rurality);and 7) RHC participation in ACOs will have a positive impact on cost efficiency and preventive care effectiveness. We will triangulate our analyses by using both quantitative and qualitative research methods including analysis of secondary data, survey research, and case studies. Multivariate analyses of seven years of organizational and community-related data of a panel of approximately 800 RHCs will be performed in order to develop more generalizable ideas about the factors contributing to RHC performance and outcomes. PUBLIC HEALTH RELEVANCE: Rural Health Clinics (RHCs) face numerous challenges such as serving communities with higher rates of chronic disease compared to urban communities, &attracting &retaining qualified professional staff. In analyzing how RHCs'participation in Accountable Care Organizations affects their performance, this study will assist policy leaders in making decisions that will strengthen the health care safety net in rural America.